Physical agents in the treatment of bladder tumors

NEW SERIES, VOL. IV

No.

FEBRUARY, 1928

2

PHYSICAL AGENTS IN THE TREATMENT OF

BLADDER TUMORS* EDWIN BEER, M.D. Surgical

Service,

Mt. Sinai HospitaI YORK

NEW

accompIish, and in attempting the impossible, sad faiIures naturaIIy take the pIace of the expected successes. Owing to the newness of the subject, owing to the fact that we are a11 in a stage of experimenting, it is very diffIcuIt to make use of the cases operated upon in other clinics, as wouId be necessary if we were to give a broad cross-section of the methods and resuIts in a11 the Iarge cIinics. It seems safer and wiser to present our own experience, based on the work of the head of the cIinic and of his associates who foIIow rather cIoseIy in his footsteps, for the methods of attack which have sIowIy crystaIIized are pursued by a11 members of the staff. NaturaIIy, we are a11 indebted to the work of other clinics, and suggestions, modifications, etc., are continuaIIy inducing us to make changes in detaiIs which probabIy wouId not be effected but for the constant interchange of viewpoints and ideas in meetings and through the medica press. In’gathering these 418 cases for this anaIysis, I am indebted to my associates, Drs. Hyman, Ashner, EdeIman and Mann. We have al1 foIIowed much the same technique in treating bIadder tumors, and the uniformity of approach to the probIem gives perhaps some added weight to the concIusions.

OR one who has Iived through the last twenty-five years and experienced the progressive changes in the treatment of bIadder neopIasms, a review of this sort shouId be a pIeasurabIe activity. Much, however, remains to be done before we can fee1 fuIIy satisfied with our progress and our resuIts. At the beginning of this century, the genera1 attitude towards the radica1 cure of tumors of the bIadder was pessimistic, if not hopeIess. How different the present attitude! How many changes have been effected by the introduction of new physica agents and new technique in the handIing of these serious conditions. Instead of advising “Hands off!” or drainage of urine by nephrostomies into the Ioin, we now go right ahead, at times perhaps treading ground which is better avoided, and yet often succeed where faiIure used to be the ruIe. In a11 new fieIds of therapy-and the cure of neopIasms of the bIadder may be considered new, even though attempts of the kind have been made for many years-as new methods become avaiIabIe, one is IiabIe to go too far and attempt too much, at times bringing adequate methods into disrepute. Moreover, owing to errors in judgment, one may expect of newer and untried methods more than they can * Read before the InternationaI

UroIogicaI “3

Congress

at BrusseIs

on August 4, 1927.

11-I

AmericanJournnl

of Surgery

In considering the physical we employ in the treatment tumors,

I shal1 limit

myself

Beer-Bladder agents

that

of bladder tothe foIIowing:

The treatment of benign papihomata with the high frequency currents used through the cgstoscope A. MonopoIar B. Bipolar The treatment of benign papillomata by noncystoscopic methods A. Paquelin cautery B. Electric cautery C. High frequency current (I) Diathermy (bipolar) (2) Radiotherm knife D. Alcohol to prevent implants 3. The use of radium both through the cystoscope and through a suprapubic cystostomy 4. The use of deep roentgen-ray I.

THE TREATMENT OF BENIGN PAPILLOMATA\~ITH HIGH FREQUENCYCURRENTS USED THROUGH THE CYSTOSCOPE

In LgLo, I caIIed attention to the use of the high frequency currents in the treatment of growths of the bladder. I had used the monopoIar current for the destruction of warts on the skin, and it seemed to me that with a properly insuIated eIectrode it might be possibIe to use this current through a cystoscope and under water. While contemplating this probIem, I was assured by an expert eIectrica1 manufacturer that such currents wouId burn out my cystoscope; but as soon as I tried a weII-insuIated copper eIectrode on skin warts under water through the cystoscope, I found that the instrument did not suffer and that the warts were destroyed. I derived my monopoIar current from an old roentgen-ray machine, which I have used together with more modern ones up to the present day. It is scarceIy necessary to describe here a machine for the production of the Oudin (monopoIar) and the D’Arsonval (bipolar) high frequency currents. It is, however, appropriate to caI1 attention to the effects of these two currents so as to emphasize the differences that exist between them. In brief, the potential of the Oudin is high,

Tumors

FEBRv*n~, 1928

whiIe that of the D’Arsonval is much Iower; in contrast, the amperage of the Iatter is higher than that of the former. It is of interest to study the effects of these currents both inside and outside the body. If one shapes a piece of raw beef so that there is a base, and attached to this by a pedicle a smaIIer mass of beef, one simulates the gross anatomy of a peduncuIated vesical growth. With one flat electrode at the base and the other pointed electrode touching any spot on the surface with adequate current (D’ArsonvaI), one will find that there is destruction of tissue under the smaI1 eIectrode, and at a distance in the pedicIe there is a concentration of the current which in a few moments coagulates this isthmus. A. MONOPOLAR. With the monopoIar current, similar and more extensive IocaI effects are produced under the electrode, but the distant effect in the isthmus is Iess active. Inside the bladder fiIIed with water,, with the monopoIar current one sees this distant action in the bIanching of large branches of the tumor more often than with the bipolar current, because the monopolar current attaches the growth to theelectrode more readily and by doing so aIIows of raising the growth and making it, in part or in toto, more definitely peduncuIated. The innumerabIe contacts with the bIadder war1 being broken, the current concentrates in the isthmus and coagulates its structures. B. BIPOLAR. As the bipolar current fails to produce this firm attachment between itseIf and the fronds, one does not get this idea1 distant effect as regularIy. StiII, everyone who has had considerable experience has undoubtedly seen this phenomenon even when using the bipolar current, as evidenced by finding on re-cystoscopy a massive necrosis which was not evident when the previous treatment had been concluded. On the other hand, in the open bladder one gets this effect reguIarIy with the bipolar current, and one can demonstrate it as readily here as on the raw beef without even putting the electrode into the hIadder. If the tumor is seized with a

NEW SERIES VOL. IV, No. 2

Beer-BIadder

bIunt ring forceps and raised so that its fronds are fairIy free from contact with the bIadder waI1, which is we11 retracted, one can shoot the current through this forceps by touching the Iatter with the eIectrode; the forceps are heId in one hand the eIectrode in the other, and in a few seconds one sees the pedicIe bIanch, smoke, and in a moment it is burnt through compIeteIy.

FIG. I. IIIustrating

the distant

The bIadder waI1 adjacent to the pedicIe is moderateIy charred in this process. These observations have Ied me for years to strive to have a grasping forceps eIectrode made for use through the cystoscope, so that at one or two sittings one couId destroy a growth in toto by seizing it at any spot, raising it from the bIadder waI1, and then by shooting the current through, destroy its pedicIe and vascuIar suppIy in a few moments. As yet, a11 the eIectrica1 technicians who have essayed to make such a seizing eIectric forceps with a fIexibIe shaft have been unsuccessfu1. When this goa is reached, the bipoIar current wiI1 have definiteIy gained the ascendency over the monopoIar current in the treatment of benign papiIIomata that are accessibIe through the cystoscope. IntravesicaIIy, the monopoIar current, by virtue of its higher potentia1, has the effect of shooting away fragments of the growth, which effect is much Iess with the bipoIar current. WhiIe the currents are pIaying, gas is generated, apparently hydrogen, as every_ once in a whiIe, partIcuIarIy if one is treatmg a neoplasm in the anterior waI1, the gas is heard to expIode. Outside the body, one can coIIect this gas over treated beef in a test tube, and by touch-

Tumors ing a match of hydrogen

American

Journal

of Surgery

to it, get the typica gas.

115 expIosion

DANGERS

With the introduction of such powerfu1 eIectric currents within the bIadder, one might expect some serious accidents in the treatment of bIadder tumors. Fortunately, such have rareIy occurred. As the treat-

effect of the bipolar

current.

ment requires no anesthesia, it is inconceivabIe that the viscus can be perforated, for the patient complains of pain as soon as the heaIthy bIadder waI1 is touched. This is an exceIIent guide for the operator. OccasionaIIy after the treatment, as the sIough separates, a troubIesome hemorrhage occurs which is, however, readily controIIed by a second appIication of the

CAUTERIZATION

FIG.

2.

IIIustrating

the effect of the Oudin

current.

current or by the use of an indweIIing catheter in the severer bIeedings. This, in my experience, has been a very unusua1 compIication. Perhaps the greatest danger Iies in the fact that the treatment is so easiIy carried out that many unsuitabIe or maIignant cases are treated in this way for months, when they shouId have been subjected to operation if they were to have any chance

116

American Journal of Surgery

Beer-BIadder

of a permanent cure. OnIy the rarest case of maIignant papiIIary carcinoma is cured by this treatment, and if one faiIs to get the typica response, the rapid meIting away of the growth, one shouId abandon this method of treatment for the surgica1 approach. As previousIy mentioned, one occasionaIIy hears a miId detonation of the hydrogen gas within the bIadder, but as far as my experience goes, this has never produced the resuIt recentIy reported by Cassutol

Tumors

FEBRUARY, 1928

In employing the bipoIar current, the ffatpIate eIectrode is pIaced under the buttocks and AexibIe, weII-insuIated eIectrodes are used through the catheterizing cystoscope. If the monopoIar current is used, we empIoy heaviIy insuIated cabIe which is infinitely better than our oIder eIectrodes, as its insuIation does not meIt readiIy and it rareIy has to be trimmed down during the seance. We are stiI1 somewhat partia1 to the monopoIar current for the reasons set forth above, but there is no doubt that

FIG. 5.

FIG. 3. Sketch of bIadder papiIIoma: first case treated after total necrosis-of surface. Mrs. J. S., aged eighty-six. Attacks of hematuria since Igo& Treated with high frequency current in rgro. TweIve cystoscopies during the four years showed a norma bIadder. Patient Iived unti1 rgrg, when she developed a cardiac weakness and died. Figure 3 shows the papilloma. Figure 4 shows apparent necrosis foIIowing treatment. Figure 5 shows the smalI necrotic area stil1 attached in front of right ureter meatus and smaII Aat area behind right ureter meatus; the Iatter coagulated and was completely destroyed; the former was broken away with the eIectrode and coagulated.

and torn the mucosa of the bIadder. Overtreatment of a benign growth produces an edematous soIid-Iookingmass in the hIadder waI1 which cIoseIy resembIes an infiItrating carcinoma, and it requires great cystoscopic experience to recognize this pecuIiar reaction especiaIIy when it is very extensive. Another rare accident is burning or shocking the patient by the electric current. With properly insuIated cabIes, this shouId never happen, and with the eIectrodes now avaiIabIe one does not see this accident. TECHNIQUE

Having discussed the possible dangers and accidents, it is not out of pIace to say a few words about the method that we use.

both currents effect the same resuIts with aImost equal satisfaction, though perhaps Iess quickIy. At the first session, with the unanesthetized bIadder fiIIed with water, the growth is thoroughIy cauterized, the eIectrode being introduced into the fronds at numerous pIaces and the current turned on with the foot switch. If the pedicIe can be approached with the eIectrode, a11 the better, as a more massive necrosis wiI1 foIIow. If, however, this is not possibIe, one shouId try to get the eIectrode to adhere to one or more of the fronds at the first appIication of the current, and then by manipuIating the AIbarran finger, attempt to raise the growth on its pedicIe as one turns on the current again. This maneuver may,

NEW SERIES VOL. IV, No. z

Beer-BIadder

if successfu1, produce a massive coaguIation in or about the vascuIar stem so that one is astounded at the next examination to see how extensive1-y the growth has been destroyed. At the first examination one can usuaJJy recover a specimen attached to the eIectrode or floating in the irrigating fluid (water) for microscopic study. If one faiJs to get a specimen in this way, one shouId use a rongeur or biting forceps to procure a specimen, as it is very frequentIy usefu1 in deciding on the future treatment. The endurance of the operator as we11 as that of the patient pIaces a time Jimit on the Iength of each treatment, which usuaIIy Iasts from ten to fifteen minutes. As it takes from one to two weeks for the dead tissue to separate, it is wise to wait a week or so before beginning the second seance. SmaII soft benign growths meIt away so rapidJy that they are compIeteJy destroyed in one treatment, and if the monopoIar disruptive force has been used, the base is exposed and the waI1 of the bIadder can be cauterized. This is Iess often seen with the bipoIar current. Even in smaI1 growths one must wait for the sIoughs to separate and cauterize the base at the second or some Iater sitting. At the second sitting one sees that a more or Iess compIete destruction has been effected, and if the tumor has responded and is definiteJy smaIIer, and the microscope has confirmed the cystoscopic diagnosis of benign papilloma, one shouJd proceed with this therapy. If at the second or subsequent seances one faiIs to see the definite destruction of the growth, and further microscopic studies show atypica1 cell growth, one should be on guard Jest one is deaIing with a maJignant tumor. As Dr. F. S. MandIebaum, our Iate pathoIogist, has said, wherever the usua1 orderJy arrangement of ceIIs and connective tissue stroma is seen with nothing atypica1 in either, the diagnosis of a benign papiJIoma must be made. If, however, the reIationship between ceIIs and stroma is disturbed or Iost, if the ceIIs are atypica1 in size and in staining shape, and show variations

Tumors

American Journd

of Surgery

117

reactions, with or without prohferation into the stroma, a tentative diagnosis of carcinoma shouJd be made, and this diagnosis can usuaIIy be corroborated after compJete remova of the growth. After the growth has been destroyed, the smaI1 soft scar Ieft in the bIadder mucosa is often hard to locate. The heavy scars that Heitz-Bayer” speaks of are not seen in properIy treated cases, though one does see them in over-treated cases, whether the monopoJar or bipoIar current is empIoyed. DIAGNOSIS SUITABLE

AND

UNSUITABLE

CASES

There is no doubt that the weII-trained cystoscopist can usuaIIy interpret the picture and differentiate between a definiteIy benign and a definiteIy soIid maJignant growth. But in between these two * Heitz-Boyer’s numerous pubIications have somewhat obscured a very simple method. I am glad to see in his recent paper before the I I I. Congress of ItaIian Urologists that he has announced that he now destroys the growth with electrocoagulation and then appIies the monopolar current to the base so as to get soft smooth scars, which we are a11 accustomed to see. As far as Heitz-Boyer’s contributions to this subject are concerned, I have again reviewed a11 his pubIications and fai1 to comprehend why he makes this simpIe procedure so UnnecessariIy mysterious and dificuIt to understand. In America some of us spoke of the high frequency treatment as “sparking,” transIated into French as &inceIage, long before he ever took up the method in2 191 I. It was my object to introduce a reaIIy simple and effective method which could be used by the ordinary cystoscopist through the ordinary cystoscope. The modification that Heitz-Boyer suggests requires a totaIIy new cystoscope, new and special electrodes, and differs, as his French coIIeagues (Legueu, Papin and others) have observed, in none of the essentiaIs from the origina method. He claims he gets no thermic action from his very high tension current, but in another passage he speaks of the growths as being “escarifi&“’ by the current. Perhaps his current has a higher tension than that empIoyed by others, but that the sparks are coId can be easiIy disproved by appIying the electrode to one’s own skin and hoIding it from I to 2 mm. away, as Heitz-Boyer tries to do in the bladder. In his 1913 paper in the ~ournd d’urologie he speaks of sparking “h distance” (!), though he advocates pushing the growth out of the way with the electrode so as to cut through the pedicle. From a11 this it wouId appear to me that the so-caIIed modification is, in a11 essentiaIs, the technique originaIIy described in 1910; and judging fro& the paper referred to at the beginning of this footnote, Heitz-Boyer has graduaIIy come round to this viewpoint himself.

118

American Journal of Surgerp

Beer-BIadder

extremes, there are a11 sorts of pitfaIIs, and I beIieve we all make mistakes in interpretation, some of which may be fata to our patients. This decision is absoIuteIy essentia1, as one is not justified in using the high frequency currents except in benign papiIIomata, as I have aIways insisted. When inflammation is present in the bIadder, it may be most diffIcuIt to interpret the picture. In addition to the rather typica

FEBRUARY, 1928

Tumors

growths one at times obtains most varied pictures in different parts of the growth. WhiIe it is generally granted that a papiIIoma with deIicate waving fronds, grey-pink in coIor, attached to the norma bIadder waI1 by a narrow pedicIe, is aImost invariabIy a benign tumor and wiI1 respond to the high frequency current, nevertheIess from time to time one sees such a deIicate papiIIoma apparentIy responding : but

FIG. 6. FIG. 7. BIadder papiIIoma. Mrs. E. C., aged seventy-one. Attacks of hematuria for fifteen years. Treated with high frequency current in rgro. Figure 6 shows an edematous, rather solid-looking papiIIary growth. This was rapidIy destroyed and apparentIy overtreated, as seen in the pecuIiar reaction shown in Figure 7, where the base resembIed a maIignant thickening of the bIadder waI1. Linear cauterization of this area showed it was firm and sensitive. Shortlv after this treatment this reaction in the bIadder waI1 disappeared, and thirteen contro1 cystoscopies during six years showed a norma bIadder.

picture presented by a benign papiIIoma, our two greatest aids are found in the study of the response of the growth to the treatment and the microscopic study of specimens removed from the growth. Rapid and satisfactory meIting away of the growth usuaIIy means a benign process, aIthough occasionaIIy one sees this in papiIIary carcinomata. Absence of response aImost invariabIy means maIignancy. Microscopic study of specimens wiI1 aIso prove heIpfu1 if one has an experienced pathoIogist at hand. Whether the cIassification of Broders,3 based on the ceI1 differentiation which alIows him to subdivide a11 these growths into four groups varying from those of miId maIignancy to the very maIignant, wiI1 be generaIIy accepted is open to some doubt. These diagnoses are often based, on smaI1 fragments of the tumor and it is notorious that in seria1 sections of bIadder

sprouting aIways anew between treatments; and eventuaIIy at operation one finds one has been absoIuteIy mistaken and the apparentIy benign growth is onIy a papiIIary excrescence in the mucosa overIying a diffuseIy infiItrating carcinoma. SessiIe papiIIary growths with thick fronds or with fronds that have grown together, giving a more soIid appearance, are often benign and can be readily destroyed with the high frequency current. On the other hand, simiIar growths in which sonie of the fronds are necrotic are very suggestive of papiIIary carcinomata, and the microscope wiI1 often decide the question so that the faiIure of the high frequency treatment to accompIish a cure wiI1 Iead the surgeon to the proper surgica1 procedure. OccasionaIIy some of these cases may respond to the current more rapidIy if exposed to radium (applicator or seeds,) but how fre-

NEW SERIES VOL. IV, No.

2

Beer-Bladder

quentIy this happens, how much is the result of the high frequency current and how much is the resuIt of the radiation is diff&It to evaIuate. Young has been most enthusiastic for this combination, and further work may convince a11 of us of the correctness of his views. When the tumor is partIy papiIIary and partIy soIid, or when the adjacent bIadder waI1 is thickened and edematous in the cystoscopic picture, as

FIG.

8.

Wide

extraperitoneal

Tumors

American

* Cystograms may ako be of use in showing the deformation of the bIadder waI1 as we11 as the size of the growths.

of Surgery

119

extensive papiIIomatosis, also, either primary or secondary to a previous operation, are often very diffIcuIt and tedious to cure, both for the patient and surgeon. In addition, one does encounter patients who are so intoIerant, for one reason or another, that one cannot get a fair chance to use the method under discussion. AI1 these groups, together with the mahgnant cases: shouId have a more radica1 attack and their

of bladder in moderate suprapubic exposure irrigation and emptying of organ.

we11 as by recta1 or vagina1 touch,* the diagnosis of malignancy is aImost certain; but even here it is worth whiIe having microscopic contro1 so that the attack can be planned with absoIute certainty. Having excIuded as unsuitabIe a11 the above cases that do not conform to the benign group, we stiI1 have a considerabIe number of definiteIy benign papiIIomata which cannot be readiIy treated transurethraIIy with the current. I have found that tumors surrounding the sphincter, as we11 as tumors near the sphincter that bIeed profusely so that one cannot work inteIIigentIy, are very diffIcuIt to cure definitiveIy and are better off if operated upon. Cases of

Journal

TrendeIenburg

position

after

growths shouId be destroyed through the open bIadder, using the bipoIar current as a cautery, resection if possible, radium seed impIantation if non-resectable, or at times tota cystectomy. RESULTS

After a bIadder tumor has been destroyed by the use of the high frequency currents, duty to the patient is by no means finished. AI1 cases shouId be reguIarIy controIIed by cystoscopic examinations, at first in three months, then in six months, and finaIIy each year for severa years; for one of the strange pecuIiarities of bIadder papiIIomata is their tendency to recur in a new site in the bIadder, with a tumor springing up de novo perhaps years after the original growths have been destroyed. Moreover, it

120

American

Journal of Surgery

Beer-BIadder

is no rarity to see the character of these new tumors varying greatIy in degree of maIignancy from the origina growth. IncompIeteIy destroyed tumors recur in situ, but the type of recurrence just referred to, probabIy the resuIt of the irritation that Ied to the first tumor, is in every sense a new tumor rather than a recurrence in the usua1 sense. Most recurrences or “recidives,” are the resuIt of growth of ceIIs

FIG. g. Liberation

of bladder

from its bed. Division

that have been overIooked and not destroyed, whereas both the benign and maIignant “new” tumors just referred to have nothing to do with the origina growth, except in so far as they are apparently the resuIt of the same causation. If patients are not reguIarIy controIIed they are exposed to these serious dangers and, strange to say, no matter how often one emphasizes the importance of this contro1, patients, even physicians who are patients, refuse to submit to this wise precautionary measure. As the resuIt of this attitude, though we have treated many hundreds of tumors of the benign type in a Iarge number of patients with the high frequency currents through the cystoscope, we cannot give a fair statistica statement of the end-resuIts. WhiIe we have patients that were controIIed for fifteen years by cystoscopy and

Tumors

FEBRUARY, 1918

have remained perfectIy weI1, the Iargest number of cases have withdrawn from cystoscopic observation after one or two cystoscopies which showed a norma bIadder.* To cIass such cases as cured is stretching a point, for everyone who has had much experience in this fieId has seen such norma1 bIadders present years afterward either a benign papiIIoma or a carcinoma at the same or in a different site. The origina

of the urachus.

Bladder

puIIed out of abdomen.

growth may have been destroyed but the bIadder condition was not controIIed if new tumors deveIoped within the viscus. This attitude of the patient, this pecuIiarity of the bIadder in producing new tumors must be borne in mind in considering a statistica study. Statistics may teI1 the truth, but in view of the attitude of patients we cannot furnish anything approaching an idea1 tabuIation. We do know preciseIy, however, that we can definiteIy destroy the origina benign growths with these currents and that, with adequate cooperation, the benign recurrences in new sites can be equaIIy we11 controIIed. In a11 we have records of 158 patients * No matter how carefu1 one is, a tiny bud of tissue may be ovedooked and Iater a tumor of some size may be found at the old site.

NEW SERIES VOL. IV, No. +

Beer-BIadder

treated with the high frequency currents through the cystoscope, representing over 200 tumors. When the treatment was new, we used considerabIe persuasion to make the patients submit to re-cystoscopies so that we couId determine fairIy definiteIy what this therapy offered; but as time went on; this effort couId not be sustained and muItipIe controIs became Iess frequent. It is of interest in this conneCtion to note that

FIG. Figures

IO to 17 iIIustrate

the method

or technique

Tumors

Amwican

TABLE SUMMARY

158

OF

TREATED 89

cases

CASES

THROUGH

controlled

of Surgery

I21

I

OF

BENIGN

THE

PAPILLOMATA

CYSTOSCOPE

by cystoscopy

and apparently

cured. 23 recurrences.

PapilIomata treated rent, well as controlled I

Year..

_~ ~~ No. ofcases.

I 2 i3

with the high frequency by cystoscopy: 4

5

11, 6 7

T

41 16 IO 7 3 6,

8

1

9 IO II

~ I

/I

1~2

cur-

;I

12 13 14 15

~~!L1 !..__ ..,..

;..I..,

I

IO.

used in the treatment

the first 4 cases treated by this method had 7 to 13 contro1 cystoscopies after their origina tumors had been destroyed, and some were controIIed in this way fifteen years after destruction of the papilloma without showing any recurrence. The fact that a patient is alive and symptom-free years after destruction of a growth, of course, is no evidence that the bIadder is free, as I have seen some very Iarge tumors (primary) that gave none of the cIassica1 symptoms of papiIIoma of the bIadder. In the above series, numer0u.s patients beIong in this category but are disregarded in our anaIysis. Of 158 cases, 89 have been reexamined in the first year up to the fifteenth year, as shown on the tabIe, and found free from IocaI recurrence or new tumors. Twenty-three more have been

Journal

of bIadder

tumors

by open operation.

re-cystoscoped and have had IocaI recurrences, or more often recurrences in a new site either papiIIomatous (8) or csrcinomatous (15). Some have shown new benign tumors as Iate as the ninth year after destruction of the origina growth as controfIed by repeated cystoscopies, and some have shown carcinomata as late as the seventh year after destruction of the benign growth. This accounts for onIy I 12 cases out of .a tota of 158 cases. Of the 46 uncontroIIed cases, some are apparentIy we11 according to Ietters received, others have been lost sight of, and some of these have, undoubtrecurrences benign or edIy, developed malignant, whereas others have died of intercurrent maIadies, coronary disease, pneumonia, etc., without having any further bIadder symptoms.

122

American Journal of Surgery

Beer:BIadder

From the above anaIysis it wouId seem that under the present conditions we must expect about 20 per cent recurrences of growths either in the oId or in new sites in the badder if the disease once gets a footing in this organ. NaturaIIy, if incompIeteIy treated, the recurrences in the origina site be reguIarIy found and wiI1 be much &I more freuuent than those in new sites. Experienck, I beGeve, has shown very

Tumors

F~BFUJARY, 1928

reached and destroyed, and growths in intoIerant patients, usuaIIy demand more radicaI operative procedures. In 33 cases we have had to resort to the operative treatment, using the technique to be described shortIy. PAQUELINCAUTERY,ELECTRICCAUTERY ANDHIGH FREQUENCY CURRENT. During these sum-aoubic exDosures of the neopIasm, tie I;hysicaI a’gent used to destroy

FIG. II.

cIearIy that this Iatter type of recurrence in situ can be avoided by adequate treatment but, as yet, we have no way to contro1 the other type of recurrence in a new part of the bIadder, except by using the utmost vigiIance and persuading patients to submit to reguIar re-cystoscopies. 2.

THE MATA

TREATMENT BY

OF

BENIGN

NON-CYSTOSCOPIC

PAPILLO-

METHODS

ReaIizing that a11 benign papiIIomata are not amenable to the transcystoscopic or transurethra1 method of approach, it became necessary to deveIop a method of treatment for this type of case. Most papiIIomatoses, especiaIIy those so frequentIy resuking from a previous operation that has spread the disease far and wide on the bIadder mucosa, growths about the sphincter that bIeed or that cannot be readily

the growths was heat as generated by the PaqueIin cautery; but improvements led to the substitution of the eIectric cautery, and this again gave way to the use of the high frequency currents through the open bIadder. With the bipoIar current used in this way, we have a most efkient method of destroying these growths, coaguIating the smaI1 growths in situ by touching the baII erectrode to them, or, if Iarger and peduncuIated, by seizing them with a bIunt ring cIamp and touching the eIectrode to the cIamp as the growth is raised from the bIadder waI1 on its pedicIe. Here the distant action of the bipoIar current becomes very evident, Iarge pieces if not a11 of the growth rapidIy come away, aIIowing the base to be thoroughIy coaguIated with this current. If the growths are very numerous, use may be made of the so-

NEW SERIES

VOL.IV,No. z

Beer-BIadder

caIIed radio-knife or needle to cut them off eIectridaIIy through their pedicIes. This empIoys a new modaIity of high frequency current with over one miIIion oscilIations. This current concentrating at a needle point, very much Iike the de Forest needIe with which I experimented in 1908, cuts through tissue with the ease of a scalpe1 and usually cIoses the smaI1 vesseIs. With a hooked or curved needIe one can rapidIy

cut through the papihomatous pedicIe by raising the growths and slipping the needle against the pedicle.Then theexposedpedicle can be coaguIated with the baI1 eIectrode by throwing the coaguIating current into the electrode. ALCOHOL TO PREVENT IMPLANTS. After the bIadder has been compIeteIy cIeared of a11 evidences of growth, it has seemed to me that, knowing the tendency of these tumor ceIIs to impIant themselves on raw surfaces and to produce recurrences, our duty is not finished. To prevent these potential impIants, I have for years soaked the bladder and the whoIe wound with strong alcoho1 for five minutes before sewing up, and I have the very distinct impression that this is effective, together with the other measures used, in physicahy destroying any Ioose ceIIs that might be floating

Americi~n Journalof Surgery

Tumors

123

free and might grow into tumors. I have seen patients suffering from recurrent papiIIomata after repeated suprapubic operations submit to the above type of operation for genera1 papiIIomatosis of the bIadder and become compIeteIy cured and weI1, controIIed by cystoscopy for years after the Iast operation. Judging from the controIIed cases, it wouId seem that the chance of cure in these

TABLEII SUMMARY

OF

33

CASES

PAPILLOMATOSIS SUPRAPUBIC QUENCY

WITH

TREATED CYSTOTOMY

OUT

THE

survivors’ Year . . . . . 1-I’1 I I ___ _~~ No. of cases 31 r

2

61

PAPILLOMA

WITH

OR

OPERATION.

OPEN

WITH

CAUTERIZATION,

HIGH OR

FRE-

WITH-

RADIO-KNIFE

Mortality: 12 per cent 15 per cent Recurrences: ApparentIy weI1: 17 cases,

Apparently

BENIGN BY

or

60 per

cent of operative

/, 3 ! 4 /1 5 / 6 1 7 .,,

I)

weI1, controlled

2;

I

8 ~ 9 ‘IO

I ..i 3 1 ..I..

by cystoscopy,

operated causes is somewhat better in the cystoscopic series I4 per ,

I I cases.

than cent

recurrences in those controIIed; but there is a primary mortality of 12 per cent pIus attached to this procedure, which is surely h*rg h er than in the cystoscopic treatment.* * Our records show I fataIity in the cystoscopic method

caused by a bacteremia

following

cystoscopy.

I24

American

Journd

of Surgery

Beer-BIadder

Of 29 cases surviving operation, 20 were folIowed and 17 were apparently cured, or 60 per cent.* It is difficult to see why these cases shouId not suffer from new benign or maIignant tumors just as often as the first series. More extensive experience wiII probably cIear up this point, as more cases submit to reguIar cystoscopic contro1. As I consider a11 steps in this operative procedure of fundamenta1 impbrtance,

Tumors

FEBRUARY, rgz8

removed a11 the cancerous depots in the bIadder wal1 or not, whiIe in papiIIary tumors such diff&Ities are much Iess frequent, for the obvious reason that one can see the growth in its entirety. The cure of cases of papiIIomatosis speaks we11 for a surgica1 procedure and is an exceIIent test of such a procedure, whiIe frequent recurrences speak against such a procedure. Even under oIder, methods, when Iess

FIG. 13.

aimed as they are against impIanting tumor ce1I.s in the bIadder or in the parieta1 wound, the foIIowing description and iIIustrations are presented. TECHNIQUE

The more carefuIIy one studies the resuIts of surgery of bIadder neopIasms, the more evident it becomes that successfu1 treatment depends upon the avoidance of tumor ceII impIants; for recurrences, except in the infiItrating malignancies, where they may be due to incompIete operations, are usuaIIy due to such impIants. The successfuI treatment of papiIIary tumors, benign or malignant, is, strange to say, a better test of treatment than that of infiItrating carcinomata, as in the Iatter it is aIways difficult to determine whether one has * Eighty-five per cent of followed cases.

attention was given to the impIant aspect of the probIem, occasiona operative cures were scored. Under the present technique, resuIts are ever so much better. I have favored the extraperitonea1 approach4 since IgI 2, and Squier, VoeIker, Latzko, as we11 as others, use the same approach in cases demanding bIadder waII Briefly, the technique foIIows: excision. I. The bIadder is gentIy irrigated and then emptied so that when it is opened the wound is not flooded with ffuid containing tumor ceIIs. 2. The patient is pIaced in a moderate TrendeIenburg position and a wide vertica1 suprapubic incision is made. 3. As the bIadder is exposed extraperitoneaIIy, it is freed from its bed of fat and peritoneum by bIunt dissection to either side of the urachus, which is doubIe

NEW SERIES VOL. IV, No. 2

Beer-Bladder

cIamped and cut between. The clamp on the bladder end of the urachus is used to draw the bladder forward and towards the symphysis as the peritoneum is sponged off its posterior surface. This may be opened accidentaIIy and wiI1 aIIow paIpation of the extent of infrItration, etc., of the waIIs of the bIadder. 4. After the bladder has been we11 freed down to or beyond the trigone in’thismanner,

FIG.

the perivesical space is carefuhy packed off with several layers of gauze abdominal pads, which protect the perivesica1 space and the incision in the parietes. 5. Then, depending upon the position of the growth or growths, the bIadder is incised either through its anterior, its posterior or its IateraI waIIs. The incision shouId be graduaIIy enIarged so that wipes or suction can sponge up the IittIe Auid that may be in the viscus. Sponging within the bIadder shouId be reduced to a minimum. As the incision is enIarged the papiIIary growth wiI1 become evident, and it is immediateIy cauterized in situ with the bipolar current, as previously described or with the electric cautery (hook) or with the PaqueIin (hooked point). In cases of muItipIe growths each growth is separateIy burnt, and every suspicious spot is treated

Tumors

American Journal of Surgery

125

similarIy. A too-extensive cauterization is preferable to one too-superficial. 6. Having a rather deep cavity to expose, it is wise to use retractors of different sizes and Iengths, rather than automatic retractors, * so that a11 surfaces of the organ can be gone over readiIy, and none are covered except momentariIy by the blades of the retractors. Again, to hold the organ we11 out of the body, cIamps without teeth are

14.

applied to the bladder incision as it is being made. The use of clamps with teeth such as the Kocher, which produce minute perforations in the bIadder waI1, thus possibIy producing impIants, shouId be avoided. 7. Being satisfied that a11 the visibIe tumor or tumors have been destroyed, our next efforts are directed against possibIe ceI1 impIants. These may be in the bIadder incision, Ioose in the bIadder or on the gauze protective packings about the organ. The incision which opened the bIadder may be IightIy seared with the eIectrode, proceeding from cIamp to cIamp in orderIy fashion, each clamp being removed in turn as the cauterization proceeds. Then the tabIe is Iowered, and the whoIe wound is fiIIed for about five minutes with aIcoho1, *An automatic retractor essentia1 and heIpfu1.

in the parieta1 wound

is

126

American Journal of Surgery

Beer-BIadder

Tumors

FEBRUARY,1928

the bIadder being aIIowed to sIip back into its bed so that its cavity as we11 as the protective gauze is exposed to the effects of the aIcoho1 which it is hoped wilI coaguIate any potentia1 ceII impIants that have broken away during the various manipuIations. 8. After this thorough bath in aIcoho1, the gauze protective packings are removed and fresh gauze is substituted. The bIadder is sponged dry and its incision cIosed, after

be dif%icuIt to decide whether there is an infiItrated base. If there is doubt, it is we11 to pIace some radium seeds in the suspicious area, running them obIiqueIy to the Iumen of the bIadder Iest one produce an extravesica1 infection by introducing the seed too deepIy into the mobiIized bIadder waI1. In maIignant tumors of the bIadder, papiIIary carcinomata and soIid infiItrating

making provision for suprapubic tube drainage. In cIosing the bIadder, a Iayer of pIain catgut sutures is used to infoId the charred edges of the incision, and over this a Iayer of chromic gut is applied to support the first Iayer. g. The incision in the parietes is cIosed in Iayers, and drainage with rubber dam or gauze to the bIadder, both above and beIow the tube which enters that organ, compIetes the procedure. From a consideration of the above points, I beIieve it wiI1 be agreed that everything that can be done to minimize the danger of impIants has been utiIized and it must be evident that such a thorough technique couId onIy be carried out through an extraperitonea1 approach. After the pedicIe of these apparentIy benign tumors has been coaguIated, it may

carcinomata, wherever possibIe we resect after mobiIizing the bladder; in the former, usuaIIy a Iess wide resection is required than in the Iatter; in some cases part of the bIadder waI1 is destroyed and radium seeds pIaced in the base. In tumors of the posterior waII which are IiabIe to extend to the serosa, it is advisabIe to enter the peritonea1 cavity before opening the bIadder: then as the bIadder is mobiIized, the invoIved serosa can be Ieft attached to the growth and the opening in the peritonea1 cavity can be cIosed prior to incising the bIadder waI1. Here again we coaguIate with diathermy the whoIe surface of the growth with one poIe in the bIadder, and with the radio-knife we make a rapid resection. If a ureter is invoIved it is reimpIanted, after the ffooding with aIcoho1, by the simpIest technique drawn into and attached to the

NEW SERIES VOL. IV, No. z

Beer-BIadder

inside of the bIadder without any tension and aIso fastened to the outer waI1 of the bIadder with a coupIe of chromic gut sutures. By using the radiotherm and diathermy in this way, we often do an extensive resection without tying a single bIood vesse1. If a vesse1 must be cIamped, its lumen is readiIy cIosed by touching the diathermy current eIectrode to artery forceps. This coaguIates the tissue at the bite

Tumors

American Journal of Surgery

I27

case, cystoscopic controIs were negative, the Iast being four years after theoperation. Since 1912 there have been 28 cases of papiIIary carcinoma, in 15 of which part of the waI1, though not the whoIe thickness, was resected and cauterized, with actua1 cautery originaIIy and Iater diathermy, and in 13 cases the whoIe thickness of the bIadder waI1 was resected. In 3 cases radium seeds were introduced into the coaguIated

16.

and the forceps may be removed without any bIeeding. a great many cases UnfortunateIy, present themseIves so far gone in their maIady that this more or Iess idea1 resection cannot be done. If one takes onIy the simpIer cases, the operative mortaIity wiI1 be correspondingIy Iow, but if a good resuIt has been obtained after a most extensive resection, one is 1iabIe to fee1 encouraged to attempt a repetition, or even attempt more hopeIess cases. This frame of mind is quite naturaI in developing a fieId in which the therapy has not been stabihzed. Previous to 1912, I find records of 5 cases of infiItrating carcinomata done transperitoneaIIy, of whom 2 died in the hospita1, 2 deveIoped IocaI recurrences, and I was cured, but died of apopIexy six and a haIf years after the operation. In this

base. The mortaIity in this series was 14 15 are per cent. Of those that survived, aIive and apparentIy weI1, or 60 per cent of the 24 who survived operation. Four couId not be traced; 6 had recurrences (25 per cent), and of these, I was re-operated and is we11 one and one-haIf years after second operation. TABLE SUMMARY

III

OF 28 CASES OF PAPILLARY CARCIKOMA TREATED BY OPEN OPERATION

AS

Operative mortality: 14 per cent Recurrences: 25 per cent ApparentIy wel1: 15 cases, or 60 per cent of those surviving operation, as controIIed by cystoscopy:

From this smaI1 series one cannot decide whether the whoIe thickness of the bIadder

128

American Journal of Surgery

Beer-BIadder

waII shouId be removed. Some of the oIdest cases had onIy a partia1 remova of the bIadder waI1. AI1 in aII, there is no striking difference between the end-resuIts that can be attributed to the amount of bladder waI1 removed, which is probabIy due to the fact that there was no extensive infiItration at the pedicIe. From the few cases in which radium was used, no deductions can be made, though I case has gone three years since the operation.

Tumors

FEBRUARY, 1928

The mortaIity in the 18 cases with ureter transpIantation (2 simpIe Iigations) was the same as when the ureter was not invoIved. Of this group, I patient was aIive and we11 aImost ten years, I six years, I five years, I three years, I a year and a haIf. The fiveand three-year we11 cases were controIIed by cystoscopy. The end-resuIts to date wouId be, 5 patients we11 out of 14, or 35 per cent, which is better by a IittIe than the whoIe group of resected infiItrating soIid

FIG. 17.

carcinomata. This may be due to the fact naturaIIy, was more that the excision, extensive. It is of interest to note that in this group 4 cases had preoperative deep roentgen ray about three weeks prior to operation, with the object, usuaIIy, of shutting off the vascuIar and perhaps the Iymphatic channeIs, to avoid dissemination by the operative trauma as we11 as to devitaIize the TABLE IV TABLE OF 37 CASES OF INFILTRATING CARCINOMA carcinoma ceIIs (though histoIogica1 studies TREATED BY RESECTION WITH OR WITHOUT URETER did not confirm this), The fibrous tissue TRANSPLANTATION about the bIadder, resuIting usuaIIy from Operative mortahty: 21 per cent 43 per cent such roentgen-ray exposure, renders the Recurrences: Apparently wel1: 13 cases, or 35 per cent of those operation of extraperitonealization more surviving the operation diffIcuIt, but in view of the fact that a11 4 Year . . . . . . .!--I1 I j 2 / 3 1 4 / 5 ) 6 1 7 1 8 1 9 110 cases faiIed to deveIop recurrence, this shouId receive further consideration and No.ofcasesl 2 12 m2 ~ I 12 ~ I ) I / ..I ..I I study. In this group as we11 as in the preceding ApparentIy weI1, controIIed by cystoscopy, 6 cases.

The most diffIcuIt cases to treat are the definiteIy infiItrating carcinomata, of which we resected 37 cases, with re-impIantation of the ureter in 17 cases. Eight cases died in the hospita1 (2 I per cent) ; 16 cases are fairIy definiteIy known to have deveIoped recurrences; and 13 cases are aIive, 6 of them controIIed by cystoscopy and with no recurrence.

NEW SERIES VOL. IV, No.

Beer-BIadder

2

group, the physica agents, the high frequency current in the form of eIectrocoagulation, or diathermy with the radioknife, has sureIy introduced a change for the better, even though we are not justified in considering the above 28 cases as deliniteIy cured. In these cases the bioIogica1 variations of the tumors are such that even after five years foIIowing a tota cystectomy, I have found at autopsy carcinoma tissue in the iIiac gIands and aIong one ureter. These patients also object to re-cystoscopy which, moreover, in a deformed resected bIadder may be inconcIusive. The best we can do is to determine whether they are aIive and apparentIy weI1, reaIizing that there is aIways a danger of recurrence which wiI1 bring our statistics of satisfactory end-resuIts to Iower figures. 3.

THE

USE

SCOPE

OF RADIUM AND

THROUGH

THROUGH

A

THE

CYSTO-

SUPRAPUBIC

CYSTOSTOMY

One of the most recent physica agents to be used effectiveIy in bIadder neopIasia is radium. In 191 I, with an inadequate suppIy, I tried this without success and shortIy thereafter, reading Paschkis’ unfavorabIe report, I abandoned my efforts for years, though originaIIy I feIt that it might prove as usefu1 as the high frequency currents used through the cystoscope, if not more usefu1. Under the great stimuIus of B. Barringer, this fieId was again expIored, and we treated 16 cases with radium emanations introduced through the cystoscope. There were two types of cases in which it was empIoyed: first, in patients with muItipIe tumors which varied in their appearance from soft typica benign to aImost soIid growths. In these, specimens from the former tumors were microscopicaIIy benign, and from the latter carcinoma was reported. Into these solid growths I to 4 seeds of 235 mc.* were introduced, and then at the next sitting the necrotic growths were further annihilated with the high frequency * OriginaIIy gIass seeds of $5 to f$ mc. were used, but of Iate, pIatinum seeds of 235 mc.

Tumors

American

Journal

of Surgery

129

currents. In these cases we had exceIIent resuIts. In the second group, we imbedded seeds because, owing either to the position of the growth near the sphincter or to the genera1 condition of the patient which made operation seem inadvisabIe, our resuIts have been most unsatisfactory. This is probabIy due to the fact that it is impossibIe to pIace the radium reguIarIy where it wiII destroy the whoIe tumor, the procedure even in the open bIadder being somewhat of a “hit-or-miss” affair. In al1 we have used radium through the cystoscope in 16 cases. In 8 cases we have had exceIIent resuIts and the tumors have been destroyed; these beIong in the first group. In the second type, I cannot fmd a singIe cure or disappearance of the growths. Radium seeds (rareIy surface appIications as weI1) were used through the open bIadder in definiteIy infiltrating carcinomata, where the growth couId be deliniteIy felt with one finger outside and the other within the viscus and the infiItration estabIished, in 31 cases. It has been cIaimed by some that the mortaIity in this procedure is so Iow that it should be the routine method of attack in a11 maIignant growths. In our experience, the highest mortaIity was seen; I I cases died, or 33 per cent. It must be admitted that most of the cases were very extensive, often invoIving the sphincter area, and anything short of a tota cystectomy with prostatectomy wouId have been quite impossibIe to effect a radica1 excision. Wherever we couId resect, we did so. If we had permission for tota cystectomy (5 cases), we did this operation. In the absence of these two conditions, we have aIways*had radium present in the operatingroom so that we wouId not be compeIIed to do a simpIe drainage operation or a more or Iess superficia1 eIectrocoaguIation. Of these 31 cases, I treated with B. Barringer was cured of a soIid growth cIose to the sphincter as controIIed by IO cystoscopies over five years. At the eIeventh cystoscopy, a benign papiIIoma was detected in a new site on the posterior

American

130

Journal

Beer-BIadder

of Surgery

waII and destroyed with the high frequency current. One is aIive after three and threequarter years and deveIoped a papiIIary carcinoma in the posterior urethra. One was we11 and Iived three and a quarter years; one two and a third years; and 2 others Iived two years aIso without recurrence. In at Ieast 2 cases we saw no resuIt. Three cases were not controIIed, and 7 died or are suffering from their disease; 2 cases are too recent to be of any vaIue. From these figures it is seen that of the 20 cases that survived the operative procedure, 6 were cured of their original neoplasms, or 30 per cent. When we consider the type of case incIuded in this group, it is evident that radium emanations used as seeds have sureIy improved the outIook for these otherwise hopeIess cases. Before radium was avaiIabIe we a11 saw countIess cases in whom we never got further than a simpIe cystostomy, if they consented to that much. In my persona1 records I have 32 such cases prior to the radium era. In addition to these, numerous cases of recurrences foIlowing operation eIsewhere, or absoIuteIy hopeIess and untreatabIe cases are found in our records. This tragic picture we expected to see changed with the introduction of the roentgen-ray therapy. 4.

THE

USE

OF

DEEP

ROENTGEN

RAY

When the deep roentgen-ray was heraIded, we a11 turned to it with expectancy, hoping it wouId be an aid in this fieId. We used it in the primary inoperabIe carcinomata and the recurrent inoperabIe TABLE SUMMARY AND

OF RADIUM THROUGH SEEDS

GROUP

A:

16

GROUP

B:

31

CASES

v TREATED

SUPRAPUBIC USED

CYSTOSCOPICALLY

INCISION.

47 CASES seeds introduced

RADIUM

IN

Radium through cystoscope: No mortaIity 8 apparentfy cured 8 recurrence or no effect cases. Radium seeds introduced through suprapubic cystostomy: MortaIity: 33 per cent 6 cases controIIed and apparentIy we11out of the 20 that survived operation, or 30 per cent cases.

Tumors carcinomata with an aImost uniform negative resuIt. L. T. Mann has recentIy reviewed 17 cases of papiIIary carcinomata and infiItrating carcinomata of the bIadder, and in onIy 3 cases had there been any reIief of dysuria and hematuria. There were no cures and Iife apparentIy was not proIonged. As these cases were treated by various experts, the uniformity of the bad resuIts is a11the more striking. It is diffrcuIt in view of our experiences to give much credence to some of the recent reports on the efliciency of the deep roentgen-ray treatment in these conditions. Whether deep roentgen-ray treatment prior to cystoscopic high frequency treatment wiI1 prove of any vaIue, in the sense that some cIaim, of an adjuvant action between radium and the high frequency current, I do not know, but some observations have suggested that this reIation may exist. In this brief report, I have attempted to survey our experience with the various physica agents used with and without cutting operations. I regret that I cannot give a better picture of the situation and a more gIowing series of end resuIts. I have purposeIy condensed the materia1 as much as possibIe. SUMMARY

During recent years there has been ‘a great change in the outIook of patients suffering from bIadder neopIasm, owing to the introduction of physica agents. Though much has been accompJished, especiaIIy in benign growths there is stiI1 considerabIe work to be don.e in the malignant growths, especiaIIy in the infiItrating non-resectabIe carcinomata. Our experiences in over 400 cases are detaiIed in the printed report, and here I shaI1 attempt to give a brief r&urn& Amongst the physica agents empIoyed are : I. Various modaIities of the high frequency currents through the cystoscope. 2. The use of these currents through the opened bIadder combined with aIcoho1 to prevent impIantations.

New SERIES VOL. IV, No. z

Beer-BIadder

3. Resections of the bIadder with the radio-knife actuated by a very rapidIy o&Hating (I ,200,000) high frequency current. 4. The use of radium seeds (emanations) (a) through the cystoscope (6) through the open bIadder 5. The use of deep roentgen ray I. The trans-cystoscopic use of the high frequency currents has given exceIIent resuIts. Both the origina growths and any possibIe recurrence are readiIy destroyed. There are weII-recognized differences in the effect of both the so-caIIed monopoIar and bipoIar currents, the former being more explosive and of higher tension, whiIe the Iatter is of higher amperage. The distant action of the bipoIar is of great use in producing a massive coaguIation in the pedicIe, as can be demonstrated on a piece of raw beef properly shaped so as to simuIate a peduncuIated growth, or when the bIadder is open and the papiIIoma is seized and raised with a bIunt forceps and the bipoIar current is aIIowed to run down this forceps into the growth. It produces an extensive coaguIation at the pedicIe and adjacent bIadder waI1. The monopoIar current has a simiIar distant effect but much Iess marked. The idea1 treatment through the cystoscope wouId be by means of a forceps eIectrode, which couId be as readiIy appIied as the above forceps through the open bIadder. OnIy benign growths should be treated with these currents, and if in doubt as to the cystoscopic accuracy of diagnosis, a biopsy, occasionaIIy a cystogram, wiI1 aid in estabIishing the nature of the growth. Lack of adequate response to the current speaks against its benign nature. There are benign cases which do not Iend themseIves to cystoscopic treatment, e.g., extensive papiIIomatoses, tumors at the neck, or in inaccessibIe situations, tumors that bIeed profuseIy at every examination, etc., and these are treated better by open operation. The trans-cystoscopic treatment has given us in over 158 cases exceIIent resuIts.

Tumors

American

Journal

of Surgery

‘31

In about 20 per cent we see recurrences in a new situs or in Ioco, the Iatter due to incompIete destruction and the former to possibIy overIooked growths or to new growths resuIting from the origina causative agent. 2. In the operative treatment everything must be done to avoid impIants. Good exposure by extraperitoneaIizing the bIadder in the TrendeIenberg position, carefu1 packing-off of the wound, and operating on the empty bIadder assist us in reaching our goa1. The bIadder is opened with the radio-knife and as the growths present, they are coaguIated with the current and removed with the cutting needIe (curved). We used to use the PaqueIin, Iater the eIectrocautery, but for two years we have been using the radio-knife. We have had 33 cases in which this procedure was necessary, and our apparent end-resuIts with this technique are excelIent though there is a primary and considerabIe mortality. Eighty-five per cent of the survivors are apparentIy cured. We say apparentIy, for it is diffIcuIt to teI1 when a case is to be cIassed as cured, having seen, five years after a tota cystectomy and apparent heaIth, carcinoma in the Sac gIands. Cystoscopic contro1 is essentia1 and it is notorious how diffIcuIt it is to persuade patients to submit to reguIar reexaminations. We are convinced that flooding the wound with strong aIcoho1, which coaguIates potentia1 impIants (free tumor ceIIs), has been of greatest vaIue. 3. In carcinoma cases, the papiIIary and the infiItrating, we use practicaIIy the same technique as under (2) coaguIating the growth and then resecting. We aIways have radium present so that in case the growth cannot be resected, we can try to destroy it with this physica agent. Of this group we have had 65 cases (28 plus 37) with apparent good resuIts in 60 per cent of the papiIIary carcinomata and 35 per cent of the infiItrating carcinomata. 4. Radium emanations we have empIoyed in 16 cases trans-cystoscopicaIIy,

132

American Journal of Surgery

Beer-BIadder

with apparent successes in 50 per cent; whereas radium apphed through the open bIadder in non-resectabIe growths, usuaIIy at or near the sphincter, has given us our highest mortaI&y (33 per cent), and only 6 cases (30 per cent) of the tota of 3 I cases seemed to be cured. L;. In 17 cases of carcinoma. we tried the deep roentgen ray without any curative effect, though occasionaIIy there was some amehoration of the symptoms. From this summary, it is evident that the picture has changed materiaIIy, and J

Tumors instead growths, we can far from

of advising “Hands off!” in these we are now getting resuks that be proud of, even though we are the goaI at which we are aiming. REFERENCES

I. CASSUTO, A. ExpIosion dans Ia vessie au cows d’une CIectro-coaguIation. J. BUrol., rgz6, xx, 263. 2. HEITZ-BOYER. Assoc. fraqaise d’urol., Session xq, _. July, 191 I, v, 790, 781. 3. BRODERS, A. C. EpitheIioma of the genito-urinary organs. Ann. Surg., Phila., 1922, Ixxv, 574. 4. The iIIustrations of the extraperitoneal approach are from BEER, E. Technic of operative treatment of neopkms of the urinary bladder. Ann. Surg., 1921, LYXIII, 75.